MRI of brachial plexus using diffusion tensor imaging: a pilot study for the use of resolve sequence surgical and radiologic anatomy.

BACKGROUND: Clinical exam is the goldstandard for surgical indication. ENMG and conventional MRI are insufficient to understand the highly variable clinical presentation of brachial plexus (BP) lesions. DTI is based on motion of water molecules and can explore nerve function. PURPOSE: This pilot study of healthy subjects aimed to develop RESOLVE sequence for BP exploration using diffusion MRI. The main objective was to provide complete precise information from DTI cartography associated with anatomical data. METHODS: Six healthy volunteers were scanned using 3T PRISMA scanner with anatomic 3D STIR SPACE and RESOLVE diffusion sequences. Diffusion parametric maps of fractional anisotropy (FA) were extracted from RESOLVE acquisitions. A reproducible method for roots volumes and angles measurements was created using 3DSlicer. ROI were segmented on Mean B0 sequences. FA measurements were obtained with ROI on Mean B0 sequences. RESULTS: RESOLVE sequence was adapted to the BP. Mean FA was 0.30. Angles measurements on 3D STIR SPACE sequences showed increasing values from proximal to distal roots with an 0.6 ICC. Volume measurements on anatomic sequences varied widely from one root to another but did not show any significant difference on laterality. CONCLUSIONS: A new and reproducible method for BP exploration was developed, using MRI RESOLVE DTI sequences. Complete mapping was obtained but a low resolution of track density imaging did not allow to exploit distal nerves. Deterministic tractography principal limit was the lack of resolution. Extraction of diffusion, volumetric and angular parameters of the plexus roots, and scripts creation for image processing was adapted to the healthy BP.

Conventional versus fibrin-glue-augmented arterial microanastomosis: An experimental study.

The purpose of this experimental study was to develop an alternative technique of arterial microanastomosis using only 2 stay-sutures augmented with fibrin glue, and to compare it to the conventional technique in arteries of varying diameters mimicking hand arteries. Eight anastomoses were performed in 7 male rats, including 1 anastomosis each on the 2 femoral, iliac, and carotid arteries, and 2 on the subrenal aorta. The conventional technique was used on one side and on the first aorta anastomosis, while augmented anastomoses were performed on the other side and on the second aorta. Patency was tested 10 min after unclamping; clamping time, blood loss, anastomosis quality score (out of 15 points) and artery diameter were recorded. In arteries of diameter 0.5-2.2 mm, augmented anastomoses were on average 10.7 ± 3.2 min faster to perform (p < 0.0001), with an average of 1.3 ± 0.9 g less blood loss (p < 0.0001) and an average of 2.6 ± 2.5 points higher quality score (p < 0.0001). There were no significant differences between the two techniques in terms of patency rate, regardless of artery size. However, 3 of the 7 augmented anastomoses were non-permeable in the femoral subgroup (i.e., submillimetric arteries). This straightforward technique appears to be time-saving and reliable, provided that the repaired artery is of sufficient size. Subject to clinical validation, this technique might help surgeons treating extensive hand wounds with multiple severed neurovascular bundles.

Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy.

Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.

Forearm reconstruction by induced-membrane technique after sarcoma resection in children: technique and functional outcome in three cases.

Forearm sarcoma is rare in children. Here, we report three cases. One child presented undifferentiated soft-tissue sarcoma involving the ulna, another had Ewing's sarcoma of the ulna, and the third had Ewing's sarcoma of the proximal radius. In the first case, there were episodes of iterative aseptic nonunion, treated surgically. At last follow-up (respectively 11, 9 and 8 years postoperatively), the mean Musculoskeletal Tumor Society (MSTS) score was 80%, 90% and 77% respectively, and all cases were in remission. The induced membrane technique to reconstruct bone defect after sarcoma resection in children is a possible limb-salvage strategy.

Treatment of congenital syndactyly.

Defined as the union of two adjacent digits, syndactyly is one of the most common congenital deformities. The severity of the malformation depends on the fusion level, the tissues involved in the union, and whether it is isolated or syndromic. In order to improve the hand's appearance and function, surgery is recommended in the great majority of cases, ideally during early childhood (i.e., before entering school). Web space reconstruction is done using local flaps. Depending on the flap design, digital resurfacing can be done with or without skin grafts. While graftless techniques have shorter operating times and no morbidity associated with skin harvesting, their cosmetic outcomes seem to be worse than those of traditional grafting techniques, with more postoperative complications; furthermore, such techniques cannot be used in all cases, especially those with osteoarticular fusions. When the fingertip is involved, paronychial reconstruction is carried out with pulp flaps. The prognosis for these deformities directly depends on their severity, with excellent outcomes in cases of cutaneous fusion, and much less predictable ones when osteoarticular and/or tendinous tissues are involved.

Factitious disorders in the hand-Main diagnostic traps highlighted with 3 cases.

Every doctor can be confronted, during his career, with patients presenting symptoms they created themselves. Because it is easily accessible, the hand is a favored target organ for these self-inflicted injuries. The diagnosis of factitious disorder of the hand is very difficult, rarely suggested and widely under-estimated. The real issue is detecting it early on to develop a cohesive diagnostic and therapeutic approach. The three clinical cases reported in this article illustrate the difficulty of caring for this pathology at all stages, from diagnosis to treatment. These disorders must be distinguished from malingering. A psychiatrist must be part of the treatment team. The prognosis of factitious disorders is poor. It is vital to maintain contact with the patient once the diagnosis is established. The risk is that the patient consults with other professionals, restarting a new cycle. The featured clinical cases were chosen to remind surgeons that factitious disorders of the hand are a recognized psychiatric disease. It must be evoked in the context of an unusual injury with a vague history. Everything possible must be done to confirm the diagnosis and avoid surgery.

Nerve transfer to biceps to restore elbow flexion and supination in children with obstetrical brachial plexus palsy.

PURPOSE: Nerve transfers to restore elbow flexion have been described for traumatic brachial plexus palsy in adults. Indications are less frequent in infants and the results are less published. METHODS: Ten patients with obstetrical brachial plexus palsy were operated on for lack of flexion against gravity with ulnar or median nerve transfer to biceps motor branch. The primary endpoint was improvement in elbow flexion and supination. RESULTS: Mean age at surgery was 12.5 months and mean follow-up was 2.6 years. The Active Movement Scale (AMS) was used to evaluate elbow flexion and forearm supination. At the last follow-up, the average AMS score improved from 0.3 to 5.7 for elbow flexion and from 0.6 to 5.8 for forearm supination. There was no statistical correlation between the age at surgery and the AMS score 18 months post-operatively. CONCLUSIONS: Nerve transfer to the biceps motor branch can improve elbow flexion and forearm supination in selected patients with upper lesions and can be safely performed until the age of two years.

[Distal radius fractures in children]. / Les fractures de l'extrémité distale du radius chez l'enfant.

Metaphyseal and physeal fractures of the distal radius are common in children. Most cases are best treated with closed reduction and cast immobilization. Long-term outcomes of these injuries are excellent when specific treatment principles of reduction and casting are followed. Surgical indications are limited and include open fractures, intra-articular fractures, non-reducible fractures, unstable fractures, and the presence of associated nerve injury. Closed reduction and percutaneous pin fixation is the most commonly used surgical option. The clinician should be aware of delayed complications such as growth disturbance of the distal radius, and understand how to manage these problems to ensure successful long-term outcomes. Epiphysiodesis is uncommon but growth plate injuries need to be followed for one year.

Distally based sural flap for ankle and foot coverage in children.

BACKGROUND: Coverage of soft-tissue defects of the ankle and foot is often challenging. The distally based sural fascio-cutaneous flap is useful for reconstructing the lower leg, ankle, heel, and foot but has rarely been evaluated in paediatric patients. The objectives of this study were to assess the reliability of this flap in paediatric patients, to describe the complications associated with its use, and to define its indications in paediatric patients with soft-tissue defects of the ankle and foot. HYPOTHESIS: We hypothesised that the sural flap was reliable for covering soft-tissue defects at the ankle and foot in paediatric patients. MATERIAL AND METHODS: A distally based sural fascio-cutaneous flap was used to cover soft-tissue defects of the ankle and foot in 20 paediatric patients between 1997 and 2013. The evaluation at last follow-up included a physical examination and determination of the modified functional Kitaoka score. Mean follow-up was 50.6 months (range, 10-192 months) and mean patient age at surgery was 8.8 years (range, 1.5-17 years). Trauma was the most common cause of soft-tissue defect (n=12); other causes were surgical-site infections (n=2), tumours (n=3), chronic ulcer (n=1), burn injury (n=1), and infusion fluid extravasation (n=1). RESULTS: Of the 20 flaps, 16 (80%) remained fully viable, whereas 4 developed partial necrosis requiring excision and skin grafting, which consistently ensured a good outcome. Other complications consisted of marginal necrosis (n=4), unsightly donor-site scars (n=5), and infection (n=2). Abnormal flap sensation was noted in 11 patients. The mean modified Kitaoka score was 65/80 (range, 0-80), and the score value indicated that function was excellent in 9 (45%) patients, good in 9 (45%) patients, and poor in 2 (10%) patients. DISCUSSION: The distally based sural fascio-cutaneous flap is a method of choice for covering soft-tissue defects of the ankle and foot in paediatric patients. This reliable flap spares the major blood vessels and has a strong blood supply. Its best indication is coverage of an acute traumatic soft-tissue defect with exposure of a vital structure. In patients requiring late reconstruction, caution is in order when considering the use of a distally based sural fascio-cutaneous flap, which can induce delayed complications, most notably at the donor site. LEVEL OF EVIDENCE: IV, retrospective case-series study.

Wrist arthrodesis in adolescents with cerebral palsy.

UNLABELLED: Twenty adolescents with severe spastic deformities of the wrist (Zancolli type 3) and poor function on the House score were operated on between 2009 and 2014, and included in this retrospective cohort study. All were treated by wrist arthrodesis combining a proximal row carpectomy, curetting of the distal radius in order to imbed the capitate and a dorsal locking plate. The primary endpoint was improvement in the House score. Secondary endpoints included pre- and postoperative wrist flexion deformity, bone union, patient satisfaction regarding appearance and complications. The mean follow-up was 22 months. The mean age at the time of surgery was 16.2 years. Additional soft-tissue release was necessary in eight wrists. The mean House score improved significantly from 0.9 to 2.7. Average flexion deformity improved significantly from 66° to 10°. Bony union was achieved in all patients within 6 months. Four of the 20 patients required hardware removal because of fixed extension of the middle metacarpal. Wrist arthrodesis combining proximal row carpectomy with the use of a dorsal locking plate is a safe and reliable technique to improve function and appearance. LEVEL OF EVIDENCE: IV.

Isolated C5-C6 avulsion in obstetric brachial plexus palsy treated by ipsilateral C7 neurotization to the upper trunk: outcomes at a mean follow-up of 9 years.

Cervical root avulsions are the worst pattern of injury in obstetrical brachial plexus injury (OBPI). The prognosis is poor and the treatment is mainly surgical with extraplexual neurotizations or muscle transfers. We present the outcomes of a technique performed in our institution to treat C5-C6 avulsion in obstetrical brachial plexus injury. This technique consists of a total ipsilateral C7 neurotization to the upper trunk. Ten babies with isolated C5-C6 root avulsion were operated on; we were able to review nine of them at over 12 months follow-up. The shoulder and the elbow function were assessed, as well as the Mallet Score. The mean follow-up was 9.2 years (SD 5.7). After a follow-up of 6 years, elbow flexion was restored with a range of motion ⩾130° and a motor function ⩾M3 in all patients. The average Mallet score was 18.1 (SD 1.2). This approach appears to be a viable alternative to extraplexual neurotizations for the treatment of C5-C6 nerve root avulsion.

Treatment of severe radial club hand by distraction using an articulated mini-rail fixator and transfixing pins.

INTRODUCTION: Treatment of severe radial club hand is difficult. Several authors have emphasized the importance of preliminary soft-tissue distraction before centralization. HYPOTHESIS: Treatment of severe radial club hand by articulated mini-rail allowing prior soft-tissue distraction improves results. MATERIAL AND METHODS: Thirteen patients were treated sequentially, with an initial step of distraction and a second step of centralization. The first step consisted in fitting 2 mini-fixators, one in the concavity and the other in the convexity of the deformity. Four transfixing wires through the ulna and metacarpal bone connected the 2 fixators. After this preliminary distraction, the fixator was removed and a centralization wire was introduced percutaneously, with ulnar osteotomy if necessary. Sagittal and coronal correction was measured on the angle between forearm and hand. RESULTS: Mean age at treatment was 37.5 months (range, 9-120 months). Mean distraction time was 53.2 days (26-90 days). Ulnar osteotomy was required in 8 cases (61%). There were no major complications requiring interruption of distraction. Sagittal and coronal correction after centralization reduced mean residual forearm/hand angulation to<12°. DISCUSSION: Soft-tissue distraction in the concavity ahead of centralization is essential to good correction, avoiding extensive soft-tissue release and hyperpressure on the distal ulnar growth plate. There have been several studies of distraction; the present technique, associating 2 mini-fixators connected by threaded K-wires, provided sufficient distraction in the concavity of the deformity to allow satisfactory correction in all cases. Subsequent complications (breakage or displacement of the centralization wires) testify to the complexity of long-term management. CONCLUSION: The present study confirms the interest of a preliminary soft-tissue distraction step in treating severe radial club hand.

Tendon lengthening and transfer.

Tendon lengthening and transfer are usually indicated for certain neuromuscular disorders, peripheral or central nerve injury, congenital disorder or direct traumatic or degenerative musculotendinous lesion. In musculotendinous lengthening, technique depends on muscle anatomy, degree of correction required, and the need to avoid excessive loss of force. Lengthening within the muscle or aponeurosis is stable. In the tendon, however, it may provide greater gain but is not stable and requires postoperative immobilization to avoid excessive lengthening. Tendon transfer consists in displacing a muscle's tendon insertion in order to restore function. The muscle to be transferred is chosen according to strength, architecture and course, contraction timing, intended direction, synergy and the joint moment arm to be restored. Functions to be restored have to be prioritized, and alternatives to transfer should be identified. The principles of tendon transfer require preoperative assessment of the quality of the tissue through which the transfer is to pass and of the suppleness of the joints concerned. During the procedure, transfer tension should be optimized and the neurovascular bundle should be protected. The method of fixation, whether tendon-to-bone or tendon-to-tendon suture, should be planned according to local conditions and the surgeon's experience.

[Acute limping in children between 1 and 4 years old]. / Conduite devant une boiterie d'apparition récente chez un enfant entre 1 et 4ans.

Recent limping in children aged between 1 and 4 years old are often a diagnostic problem because the young child may not be able to show the area of pain. Dominated by the traumatic causes like hairline fracture, the physician should eliminate the most severe, including infectious etiologies that require urgent treatment. The clinical examination is fundamental and simple complementary investigations like standard X-rays and biology (blood count cell, C reactive protein) looking for increased inflammatory parameters will help to find the cause in the majority of cases. The persistence of a limp beyond a week involves the realization of bone scan or MRI imaging.

[Metacarpal osteoarticular injuries in children]. / Traumatismes ostéoarticulaires des métacarpiens chez l'enfant.

Metacarpal fractures and dislocations in the fingers are common injuries in children's hands. Most of these can be treated successfully non-operatively, although a subset requires more aggressive treatment. Results following appropriate care in children are generally good. Twenty percent of them need a reduction, need for surgical stabilization is rare. Each injury is presented, including diagnostic, therapeutic principles, pitfalls to prevent and potential complications.

[Finger bone and joint trauma of the hand in children]. / Les fractures, luxations et entorses digitales chez l'enfant.

The hand is the most commonly injured location of a child. Fractures of the digits are the most frequent lesions with two specific locations: 1) in the young child, the fracture is usually a crush injury, such as occurs when a hand gets caught in a door, with lesion of the distal phalanx; soft tissue associated injuries are the main problem in this location; 2) in the older child, the fracture is usually secondary to recreational sports, with lesion on the proximal phalanx of the second and fifth digits. Dislocations or sprains are less common. Most interphalangeal joint injuries occur at the proximal interphalangeal joint and are secondary to hyperextension with as results a volar plate injury. Most fingers injuries in children are treated non operatively with a favorable outcome. The treating physician should however identify those clinical situations that require surgery, as complications are most commonly due to a failure to identify and treat an injury requiring an operation acutely. These injuries include intra-articular fractures, displaced phalangeal neck fractures, and malrotated fractures. Malrotation or intra-articular malunion have no remodeling capacity. Non-union and stiff digits are uncommon but a significant trauma or a high-energy mechanism with severe soft tissues injuries appears to be a factor of risk.

[Hand injuries in children]. / Généralités sur les traumatismes de la main de l'enfant.

The hand is one of the most commonly injured locations in children. In the young child, the ignorance of dangers may explain this frequency. In the older child, hand trauma is usually secondary to recreational sports. Most hand injuries in children are treated nonoperatively because of high remodeling potential. Surgical treatments are mandatory in case of open or unstable fracture, displaced intraarticular fractures and displaced phalangeal neck fractures. In phalangeal neck fractures, percutaneous treatment should be preferred. Finger stiffness and non-union are uncommon and are usually in relation with skin or vascular involvement. In case of physis fracture, clinical and radiological follow-up should monitor any growth problems.

Inter-tibiofibular graft for traumatic segmental bone defect of the tibia.

INTRODUCTION: The present study sought to assess the interest of inter-tibiofibular graft (ITFG), alternatively called posterolateral bone graft, in traumatic segmental tibial bone defect. MATERIAL AND METHODS: Twenty-eight ITFGs were performed in 125 tibial reconstructions for traumatic bone defect. Patient's records were reviewed retrospectively in a multicenter study. Tibial reconstruction with and without ITFG was compared for bone healing and patient's return to full weight-bearing status. RESULTS: There were no failures of bone healing in the ITFG group, versus 14 (14%) in the non-ITFG group. Graft-to-consolidation delays were shorter with first-line ITFG, at a mean 10 months (range, 3-20 months) versus 16.5 months (range, 3-63 months) in the non-ITFG group (P<0.05). Weight-bearing was likewise more quickly resumed, with full weight-bearing at a mean 9 months (range, 3-19 months) versus 15 months (range, 1-34 moths) respectively (P<0.05). Return to work was also quicker, at a mean 15 months (range, 4-28 months) versus 27 months (range, 8-56 months) respectively (P<0.05). DISCUSSION: This study confirmed the interest of ITFG in tibial bone defect reconstruction. ITFG may singly be used for small defects less than 4 cm, or in conjunction with another tibial reconstruction technique; ITFG in the present series achieved consolidation in all cases and significantly shortened the times to return to full weight-bearing status and to work. LEVEL OF EVIDENCE: III: retrospective case-control study.